As a part of the Toronto Community Hep C Program, South Riverdale Community Health Centre (SRCHC) offers hepatitis C testing and treatment to people who use drugs across east Toronto in places in which they spend time and feel comfortable. One of these locations is keepSIX, a consumption and treatment service (CTS) (also known as a supervised consumption service) located inside SRCHC. As part of a recent research study, keepSIX clients were able to access hepatitis C testing and care in a co-located clinic. Testing was offered within the CTS, and clients with a hepatitis C infection accessed treatment in the same building. Of 124 participating clients, 64 (51.6%) had a current hepatitis C infection. Of the 57 participants who were eligible for hepatitis C treatment, 75.4% were linked to care and 67.4% of those linked to care started treatment within the study period. Following treatment, 86.2% received bloodwork that confirmed they were cured of hepatitis C, suggesting this care model facilitated high levels of engagement in care and treatment.
Program description
The CTS is staffed by nurses, health promoters and harm reduction workers with lived/living experience of drug use. Hepatitis C testing and care are offered to people who inject drugs using a holistic approach coordinated by a multidisciplinary team that minimizes barriers to care. The team includes CTS staff as well as a hepatitis C nurse, physicians and nurse practitioners.
Testing
Standard procedures for hepatitis C testing in Ontario require clients to provide a blood sample that is sent to a central laboratory for testing, which results in a waiting period between testing and receipt of results. For most people, two tests are done: a hepatitis C antibody test and, if the result is positive, a hepatitis C RNA test.
During this study, CTS clients were offered hepatitis C RNA testing on-site every three months. The health centre’s hepatitis C nurse administered the novel point-of-care test (GeneXpert HCV Viral Load Fingerstick) within the CTS space. The test required a finger-prick blood sample and was analyzed on site using the Cepheid GeneXpert System. Results were available to study participants within 60 minutes, with a positive test result indicating that a person currently has a hepatitis C infection.
Intake
Clients who tested positive received counselling and were encouraged to seek hepatitis C treatment. Interested clients were immediately connected to the SRCHC’s co-located hepatitis C treatment program. Intake was completed by the hepatitis C treatment nurse, including bloodwork to confirm the diagnosis and assess liver health. Clients were then referred to a program prescriber (a physician or nurse practitioner) whom they could visit during weekly drop-in hours to discuss treatment. Clients not yet ready to start treatment could begin intake at any time in the future. Staff with lived experience of hepatitis C who work within the CTS offered clients ongoing encouragement to begin treatment.
Treatment and follow-up care
On-site physicians and nurse practitioners reviewed intake assessments and prescribed hepatitis C treatment, using a dispensing plan that worked best for the client (daily with weekend carries, weekly or monthly). Medications were mailed to the client directly or picked up from the hepatitis C nurse, CTS or pharmacy. The hepatitis C nurse remained engaged in each client’s care from start to finish, updating their contact information and delivering medications, as needed.
Results
During the study recruitment period (a ten-month period during 2018 and 2019), 124 clients who inject drugs accessed point-of-care hepatitis C RNA testing. Clients were, on average, 40.9 years old and had been using injection drugs for 10.8 years. Additionally:
- 42.8% belonged to a racialized or Indigenous identity group
- 73.4% did not have access to stable housing
- 53.2% were unaware of their current hepatitis C status
During the evaluation period, 64 clients (51.6%) tested positive for hepatitis C; 54 tested positive at their first test, and 10 tested positive at a repeat test. Clients without access to stable housing were two times more likely to test positive for hepatitis C than those who were stably housed. Those who were injecting drugs daily were about three times more likely to test positive for hepatitis C than those who were injecting drugs less frequently.
Among 64 clients who tested positive, 57 (89.1%) were eligible for hepatitis C treatment (three clients cleared their hepatitis C infection without treatment and four clients died). Of those eligible for treatment, 43 (75.4%) were linked to care (i.e., had an intake assessment), 29 of whom (67.4%) began treatment. Racialized or Indigenous clients were twice as likely as white clients to begin treatment, and clients who used fentanyl were less likely to start treatment than clients who used heroin or prescription opioids. Clients who were older or who had been injecting drugs for more years were more likely to start treatment. Among those who initiated treatment, 86.2% (25/29) were tested and cured (achieved a sustained virologic response). Among clients who were not confirmed to be cured, one experienced treatment failure and underwent retreatment, while others were not tested for sustained virologic response before the end of the study period.
What does this mean for service providers?
According to the researchers evaluating this care model, clients tested positive for hepatitis C at a higher rate than estimates in the general population of people who inject drugs, which suggests the care model reached people at a high risk of infection. They note that in other Canadian studies, only 14% to 40% of people who inject drugs with a hepatitis C diagnosis accessed treatment, whereas 67% of clients linked to hepatitis C care (29/43) accessed treatment during the study using this care model. These findings suggest the evaluated model of care encouraged high levels of engagement in treatment.
Point-of-care RNA testing allowed clients to complete a hepatitis C test to find out whether they had a current infection during a single CTS visit. Co-locating hepatitis C testing and treatment within a CTS may have helped clients stay engaged in care and treatment, leading to a high proportion of clients being cured. Clients reported that trustworthy connections with health centre staff (including those with lived and living experience) were key reasons for accessing care.
Notes: The Xpert HCV Viral Load Fingerstick point-of-care test is not yet approved for use in Canada. In Ontario, CTS provide integrated, wrap-around services that connect clients who use drugs to primary care, treatment and other health and social services. In other jurisdictions, these services are more commonly referred to as supervised consumption services.
Related resources
KeepSIX Supervised Consumption Service – Case study
Hepatitis C point-of-care testing: What is its impact on testing and linkage to care? – Prevention in Focus
Reaching the undiagnosed: Advances in hepatitis C testing – CATIE and CanHepC webinar
Reference
Lettner B, Mason K, Greenwald ZR et al. Rapid hepatitis C virus point-of-care RNA testing and treatment at an integrated supervised consumption service in Toronto, Canada: a prospective, observational cohort study. The Lancet Regional Health – Americas. 2023;22:100490. Available from: https://doi.org/10.1016/j.lana.2023.100490